| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $416.00 | $416.00 | $416.00 |
Pharmacy-Extension of 025X and 063X - Reserved (Use 0250 for general c
| Insurance Carrier | Facility/Professional | Modifier | Low Price | Median Price | High Price |
|---|---|---|---|---|---|
Aetna
| Facility | $416.00 | $416.00 | $416.00 |